Lawrence S. Neinstein, M.D., F.A.C.P.
Professor of Pediatrics and Medicine
USC Keck School of Medicine
Executive Director
University Park Health Center
Associate Dean of Student Affairs
   

 

 

Substance Abuse - Questions/Cases (B8)

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Questions

Question #1 :
What is the most common drug that adolescents have used by graduation from high school?

Answer #1
Alcohol


Question #2:
What is the definition of an hallucinogen drug? Is this group of drugs able to produce either tolerance, psychological dependence or physical dependence

Answer #2
Hallucinogens are drugs that affect sensations, emotions and awareness and cause distortion of perceived reality. They produce illusions not true hallucinations.

They can produce tolerance and psychological dependence but do not appear to cause physical dependence.


Question #3
List 2 factors associated with increased risk for heavy alcohol use in an adolescent?

Answer #3

  • Family history of alcoholism
  • Extreme parenting style
  • Heavy use of alcohol among peers
  • Lack of religious involvement

Question #4:
List 4 behavioral changes suggestive of an drug abuse problem?

Answer #4

  • Changes in activity such as loss of interest in school, play, home, or work
  • Changes in sleeping patterns
  • Changes in eating patterns
  • Changes in personality
  • Manifestations of depression, such as poor attention span, difficulties in concentrating, lack of interest, and boredom
  • Trouble with law enforcement
  • Multiple or frequent accident-related injuries
  • School failure
  • Unexplained blackouts

Question #5
A teen has been smoking marijuana heavily this past week. He knows that he will be tested next week for his involvement in sports, so he stops for the next week. Is it likely that his test will be completely negative for marijuana.

Answer #5
Marijuana is a fat-soluble drug and can accumulate for long periods in the body. Thus it is possible that the test may be positive a week later.


Question #6
Match the eye findings on physical examination with the particular drug

  1. Normal sized pupil, slow or no reaction to light, conjunctival injection
  2. Constricted, non reactive pupil
  3. Dilated pupil with slow or no reaction to light
  4. Normal sized pupil with slow or no reaction to light and vertical or horizontal nystagmus
  5. Lateral nystagmus

A. heroin
B. nicotine
C. marijuana
D. PCP
E. Barbiturates
F. Cocaine or amphetamines

Answer: #6
1-c
2-a
3-f
4-d
5-e


Question #7
Using physical restraints in an individual with an overdose of LSD or PCP is a reasonable treatment to avoid injury to the adolescent and the health care provider. True or false? 

Answer #7
False. Using physical restraints might be dangerous in this setting to both the teen and the health care provider. The individual should be put in calm environment with little physical stimulation. Medications should be avoided if possible, but if needed, small doses of haloperidol could be used.


Question #8
MDMA or ecstasy has characteristics of which two types of drugs? 

Answer #8
MDMA shares both amphetamine and hallucinogenic drug effects.


Question #9
A teen is brought to the emergency room in a semi-comatose state. He has shallow breathing, low blood pressure, bradycardia and his eye exam shows miotic pupils. His friends think he has been using drugs tonight. What drug is likely and what immediate interventions make sense? 

Answer #9
This combination of physical findings suggests possible opiate overdose. It would be important to assess his cardiopulmonary status and provide adequate basic life support. In addition, provision of an anti opiate medication like naloxone would be important as well as a bolus of glucose while drawing blood for glucose levels, electrolyes, CBC and drug levels.

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Cases

A 16-year-old adolescent male is brought into your office by his parents. They are concerned that his grades have fallen off this past year and that he appears more distant than he use to. They are also concerned about the peers he is hanging out with. In the hallway, the father takes you aside and mentions that he is concerned that his son might be using drugs and wishes that his son be tested for drug use.

Question:
What approach would you take with this family and teen interview and what questions would be important to ask on the interview?

Answer:
One would need to meet with both the parents together with the teen, some time with the teen alone and perhaps some time with the parents alone to get out additional history of their concerns and why they are concerned.

It would be important to address with the teen:

  • Medical history - Are there any concerns that the teen has about his health.
    Teen is not very talkative and denies any complaints and states everything is ok.
  • Home situation:
    Teen lives with both parents and two bothers. He is oldest of the three. He states that his parents bug him a lot and he wants to be left alone. He does not spend much time with his siblings who are much younger than he is.
  • School history:
    Teen states he is not that interested in school. His grades might have dropped a bit but he feels he just has not studied as hard and his parents are always bugging him a lot about that. He is more interested in hanging with his friends, playing music with them and listening to music with them. When you discuss with parents they state that he use to be B+ student and that he now is getting mostly C's with an occasional D.
  • Activities:
    As above he likes to hang with friends and play/listen to rock music.
  • Drugs :
    Teen appears somewhat evasive about answering these questions despite reassurance of confidentiality. He states he has an occasional beer on weekends, an occasional cigarette and he smokes marijuana on some weekends.
  • Sexuality:
    He has had one or two girlfriends. He has been involved sexually with them but has not had intercourse yet with any of them.
  • Mental health:
    Teen not real eager to talk but he states he does not like living at home and is bugged by his parents interventions in his life. He has never been suicidal.

Question:
What would be important areas to focus on in the physical examination?

Answer:

  • General appearance: Would be important to check general appearance looking for signs of either malnutrition or infection suggesting either drug abuse or other chronic diseases.
  • Vital signs: Important to check for blood pressure and pulse changes associated with drug use
  • Skin: Important to assess skin for changes associated with drug abuse such as evidence of needle tracks or other rashes.
  • Eyes: Important to check for changes in pupil size or reactivity that might suggest recent drug use.
  • Nasopharynx: Check for nasal mucosal injury that might suggest nasal use of amphetamines or cocaine.
  • Mental status: Check for any evidence of depression or delusions that might be associated with drug use.
  • In addition, one would be checking on overall exam for any signs of a chronic disease that might be associated with changes that could lead to decreased school performance.

On examination, you find

  • Pulse: 110 BP 125/85 weight: 66 kg height: 173 cm Temperature: 37
  • General appearance: Appears to have a somewhat depressed affect but overall in good health
  • HEENT: Positive findings include somewhat injected conjunctiva and pupils slow to react to light. There is some moderate erythema of nasal passages.
  • LN: no adenopathy
  • Cardiac exam: no murmurs or clicks.
  • Lungs: clear to auscultation
  • Abdominal exam: BS normal and no tenderness or hepatospenomegaly
  • Skin: mild comedonal acne, no other lesions, no needle marks
  • Mental status: He appears to have slightly depressed affect. Otherwise the mental status exam is normal.

Question:
What lab tests would you order?
Would you order a drug screen as his father requested?

Answer:
Reasonable to order:

  • CBC if he has not had CBC in recent years
  • Urinalysis
  • Chemistry panel looking for evidence of any chronic disease, liver changes associated with either a disease state or drug use.
  • Drug screen: This is always a difficult question. In general, it is better to be able to get an accurate drug history from the teen and avoid a drug screen. It is also recommended in most circumstances if drug screening is done to have both the teens knowledge and permission. However, there are circumstances where this is not feasible. These certainly would include evaluation in the emergency room with teen in either a comatose state or having bizarre behavior or an unexplained accident. It would also include monitoring of compliance during treatment program. Other potential times to order drug testing include: if one is not sure about the drug history from the teen, unexplained psychiatric symptoms, significant changes in performance or behavior in daily activities or school, sudden changes in behavior or recurrent unexplained accidents

If one decides to test a teen, one should have a clear plan of action in mind, including appropriate referrals. The clinician needs to be aware that a single positive test does not determine the frequency and extent of drug use while a negative test only provides a “snapshot” of the recent use of some drugs.

There is no universal agreement about screening suspected adolescent substance abusers without their knowledge. The American Academy of Pediatrics (1989) issued a statement that involuntary drug tests should not be ordered for competent older adolescents unless they have been informed of the procedure. The American Academy of Child and Adolescent Psychiatry (1991) issued the following statement: "Confidentiality is not unconditional when the child's mental status is severely impaired or when the adolescent is judged to be in a life-threatening situation."


Question
What other steps would you take at this point with the family and the teen?

Answer:

  • Discuss drug use/concerns and testing with the teen
    You could discuss the parents concerns about drug usage with the teen and their concerns about his school performance. At the same time you could discuss his feelings about drug testing.
  • School records
    It would be important to get a perspective from his teachers of his school performance and possibilities of any learning problems.
  • Follow-up:
    Would be important to schedule a follow-up with the teen to review the laboratory tests, reinterview the teen about school, family issues and perhaps any drug use.

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